Updated 12.16.2020 COVID-19 Rapid Test Appointment and Consent Form

Select a 5-minute time slot for your COVID-19 Testing Appointment*

Submitter Name

Submitted Test Result to State [MONTH (MM)] - Post Test

Submitted Test Result to State [Day (DD)] - Post Test

Submitted Test Result to State [YEAR (YY)] - Post Test

Pharmacist Name (ordered the test)

Pharmacist NPI

Date Swab Performed [MONTH (MM)] - Post Test

Date Swab Performed [DAY (DD)] - Post Test

Date Swab Performed [YEAR (YYYY)] - Post Test

Test Result (Post test)

Detected/PositiveNot detected/NegativeInconclusive/Undetermined/Invalid/Equivocal

Type of Facility

Pharmacy

Specimen Type

Nasal

Test Name

BD Veritor System for Rapid Detection of SARS-CoV-2

Patient Identifier

N/A

Patient Name*

First nameMiddle nameLast name

Date of birth (MM/DD/YYYY)*

Date

Age*

Address*

Street Address (and unit/apt # if applicable)

Street Address Line 2

City

Zip code

State*

You may choose a different option if your State is different

County of Residence*

You may choose a different option if your County is different

Phone Number*

Sex at birth*

FemaleMaleNeither/OtherUnknown

Select the most appropriate status below regarding pregnancy*

PregnantPostpartumUnknownNeither pregnant nor postpartum

Race (select all that apply)*

Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoUnknown

Do you have any symptoms?*

YesNoUnknown

List your symptoms (if applicable)

Email Address (optional)

example@example.com

In addition to a phone call about your test results, please select your preference for an email notification.

I would like to receive my test results via an unsecured email from Duvall Family Drugs that is not HIPAA Compliant.I DO NOT want to receive my test results via an unsecured email; I will come by the pharmacy drive through to receive a hard copy.

Signature*

What is the patient's affiliation to the facility

Did the patient die?

YesNoUnknown

COVID-19 Test Appointment & Consent Form